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Hospital Assesment Hospital Assesment for for

Quality of CareQuality of Care

Country experience : Country experience : INDONESIAINDONESIA

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OUTLINE

1. BACK GROUND2. HOSPITAL ASSESMENT3. RESULT4. FOLLOW UP AFTER ASSESMENT

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HEALTH INFRASTRUCTURE

Number of:*-Hospitals (*2011) : 1686 -Community Health Centers : 9133 -Integrated service posts : 266.827- Maternity Huts : 28.558-Village Health Posts : 51.996(*2011)Number of Health Personnel*-General Practitioners : 25.333-Medical Specialists : 8.403-Obstetricians : 1104 -Pediatricians : 1800 -Nurses : 160.074-Midwives : 96.551

Background The sickest children require

hospital care IMCI assumes referral for the

sickest children

~10 (-20%) of children require referral

Child survival interventions depend on good referral system & good care at referral level

To known situation about quality hospital care as a based data

Department of Child and Adolescent Health

and Development

Finding Classification Treatment

Danger signs Severe disease Urgent referral

Cough or difficulty inbreathing

Severe disease Urgent referral

Diarrhoea

Fever

Disease with specifictherapy

Specific medical treatment

Ear problem

Nutritional status/anaemia

Disease without specifictherapy

Symptomatic treatment

Vaccination status Complete/incomplete Vaccinate

Assess and classify

5

Hospital Improvement Process

1 .Country Orientation

2 .Hospital Assessment

3 .Agreement on standards

4 .Definition of interventions & area

5 .Improvement in hospitals

7 .Sharing of Information

6 .Monitoring and Evaluation

PLAN

CHECK

DOACT

5

6

GENERIC ASSESSMENT TOOL

Indonesian assessment tool

ADAPTATION process

2006-2008

IMCIIMCI Minimal Standard of care IDAI

Minimal Standard of care IDAI Standards/guideline,

case management, hospital

accreditation instrument (MOH)

Standards/guideline, case management,

hospital accreditation

instrument (MOH)

6

1. RSU Dr R Sosidoro (B)

2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno

1. RSU Dr R Sosidoro (B)

2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno

1. RSU Raden Mattaher (B)

2. RSU Muara Bungo (C)

3. RSU Bangko (C)

4. PKM. Pemenang

1. RSU Raden Mattaher (B)

2. RSU Muara Bungo (C)

3. RSU Bangko (C)

4. PKM. Pemenang

1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala

1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala

1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga

1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga

1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers

Maumare (C) 4. PKM Bola Sikka

1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers

Maumare (C) 4. PKM Bola Sikka

1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui

1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui

04/21/23 7

Methodology: stratified 2 stage random sampling to be geographically representative

.

1. RSU Dr R Sosidoro (B)

2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno

1. RSU Dr R Sosidoro (B)

2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno

1. RSU Raden Mattaher (B)

2. RSU Muara Bungo (C)

3. RSU Bangko (C)

4. PKM. Pemenang

1. RSU Raden Mattaher (B)

2. RSU Muara Bungo (C)

3. RSU Bangko (C)

4. PKM. Pemenang

1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala

1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala

1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga

1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga

1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers

Maumare (C) 4. PKM Bola Sikka

1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers

Maumare (C) 4. PKM Bola Sikka

1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui

1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui

Methods

Assessment teams senior paediatrician, a senior nurse with experience caring for children, surveyor of hospital accreditation committee a doctor working in the ministry of health a health professional from the provincial health office

Visits 2 working days, with observations during the evening

or night. The hospital director was informed in advance and

agreed to the assessment

Based on generic WHO tool Adapted in line of tools of hospital accreditation commission Areas assessed 

1. Hospital support functions including drugs, supplies and equipment; laboratory, radiology and hospital information systems

2. Emergency care

3. Children’s ward

4. Case management on the ward

5. Neonatal care

6. Monitoring of patients in the hospital

7. Mother and child friendly services

8. Hospital support

9. Discharge and follow-up

10. Access to hospital

Hospital assessment tool

1010

RESULT OF ASSESSMENTRESULT OF ASSESSMENT

Number of hospital 18 Category class B = 7 Category class C = 9 Category class D = 2

Number of bed 30 – 323 Bed occupancy rate

57% Length of stay is 4 day

Type and number of bed of HospitalBed occupancy in Child

health care

1212

Number of general MD by training received

Trained Number of MD

Basic life support 23

Emergency services 55

ACLS 49

Resuscitation 6

BEONC 15

CEONC 5

ICU/NICU 4

Malnutrition Health Care 6

IMCI 6

EMERGENCY SERVICES IN HOSPITAL

WEAKNESSESWEAKNESSES

STHRENGTHS

STANDARD PARAMETER

Summary of assessment

To be strongly improved

(<60%)

Need to be improved(60-79%) Good

(≥80%)

1.Lay-out and structure

1-4 There are triage system, SOP triage, flow of pediatric patient, referral system.

œ    

 5.Separated emergency unit

    œ

 

6. Separated of examination and treatment room

  œ  

 7.Easy access to emergency unit

    œ

2.Emergency unit staff 1. Skillful triage staff

œ    

 2.Adequately professional staff

  œ  

3.Drug and equipments

1.Availability of emergency drug administration

  œ  

 

2-3.Availability of essential laboratory test and medical equipments

œ    

Separate emergency unit Emergency unit easily accessible Examination and treatment room

separated Adequate numbers of

professional staff Availability of emergency drugs

No triage system for children SOP not complete, especially for

children Majority no wall chart for child

cases Most of staff without training on

child cases No referral policy .

CASE MANAGEMENT IN PEDIATRIC WARD 1. Cough or difficult breathing

Most hospitals (77%) have nebulizer, X-ray, and good supply of O2 .

SOP not complete Incorrect Dx of severe pneumonia and not complying with standard Administration of second line antibiotics (cefotaxim) directly.• Salbutamol only available in 61% RS • Scoring system for child Tb Dx not implemented. Combined anti TB drugs for child not available self-mixing of incorrect dose of anti TB. •Tuberculin test not done. . Non compliance of medical record by pediatrician or physician.

WEAKNESSESWEAKNESSES

STRENGTHS

STANDARD PARAMETER

Summary of assessment

To be strongly

improved(<60%)

Needs to be

improved(60-79%)

Good(≥80%)

1. Diagnosis assessment of severe pneumonia

1. Correct assessment of severe pneumonia

œ

 

 2.Administration appropriate antibiotic, oxygen, management of wheezing, TB medication, usng chest X-ray

1-3. Correct administration of appropriate antibiotics , oxygen , Inhaled bronchodilators

œ

 

 4-5. Correct provision of TB treatment and use of chest x-ray based on clinical indication

 

œ

 

CASE MANAGEMENT IN PEDIATRIC WARD 2. DIARRHOEA

STANDARDPARAMETER

Summary of assessment

To be strongly

improved(<60%)

Need to be improved(60-79%)

Good(≥80%)

1. Assessment of dehydration

1.Correct assessment of dehydration

œ   

2. Management of rehydration, administration of antibiotics, continued feeding, and Zinc supplementation during diarrhea

Correct rehydration plan is chosen based on the degree of dehydration and monitored

œ   

.2. Correct use of antibioticsPolicy that antidiarrhoeal are not given

œ    

3. Procedures for continued feeding œ    

4.Procedure and policy for Zinc supplementation

œ    

• Availability of antibiotics and fluid

SOP not completed. No classification of the severity of dehydration and no plan of continued feeding.

All diarrhoea cases given iv fluid therapy and antibiotics directly. Antidiarrhoeals given frequently

ORS not given Zn not available in most

hospitals (67%). If Zn available, expensive (Zinc-kid Rp. 33.000/10), so not administered routinely especially for poor patients.

WEAKNESSES

STRENGTHS

CASE MANAGEMENT IN PEDIATRIC WARD 3. FEVER

STANDARDPARAMETER

Summary of assessment

To be strongly

improved(<60%)

Need to be

improved(60-79%)

Good (≥80%)

1.Assesment and differential diagnosis

1. Appropriate assessment undertaken for all children with febrile conditions and have a differential diagnosis for possible and likely conditions considered.

œ   

2. Diagnosis an management of fever

1-2.Correct diagnosis of Dengue viral infection and management of DHF with or without shock and monitored.

œ   

3-4.Correct diagnosis and management of severe malaria (with complication and appropriate antimalarial treatment are given

œ   

5-6. Correct diagnosis and management of meningitis and appropriate treatment.. œ

   

SOP not completeNo consideration of DD• No record of the severity of

DHF, excessive fluid therapy, not monitored, haematocrit test not done as routine lab test.

• Thick blood smear not done as routine test

• New guideline of malaria therapy not yet implemented and Artesunate & Amodiaquin not available in most hospitals

LP not done as routine test for patients suspected of meningitis

STRENGTH

WEAKNESS

Availability of essential laboratory tests

CASE MANAGEMENT IN PEDIATRIC WARD 3. MALNUTRITION

STANDARDPARAMETER

Summary of assessment

To be strongly improved

(<60%)

Need to be improved(60-79%)

Good(≥80%)

1. Nutritional status is assessed to all patients

1.Assesed nutritional status to all inpatient œ

   2. Management 1. Correct

assessment of hypoglycemia and hypothermia to children with severe malnutrition

œ

   2.Correct administration of antibiotics and micronutrients

œ   

3. Correct feeding to malnourish children and feeding formula is available œ

   

There were 6 physicians trained in malnutrition

No SOP /not complete SOP. Nutritional status is not assessed by height but only by weight. Scale for height not available.

Management of severe malnutrition is not compliant with guidelines.

STANDARDPARAMETER

Summary of assessment

To be strongly improved

(<60%)

Need to be improved(60-79%)

Good(≥80%)

1. Nutritional status is assessed to all patients

1.Assesed nutritional status to all inpatient

œ   

2. Management 1. Correct assessment of hypoglycemia and hypothermia to children with severe malnutrition

œ

   2.Correct administration of antibiotics and micronutrients

œ   

3. Correct feeding to malnourish children and feeding formula is available œ

   

STRENGTH

WEAKNESS

CASE MANAGEMENT IN PEDIATRIC WARD 3. HIV/AIDS

STANDARDPARAMETER

Summary of assessment

To be strongly improve

d(<60%)

Need to be

improved(60-79%)

Good(≥80%)

1.Assesment and counseling for HIV suspected children

1. Correct assessment and counseling to HIV suspected children

œ    

2. Corect nursing care for health condition related to HIV infected children œ    

Physicians and nurses are available to participate in HIV training

Guidelines or SOP were not in place for counselling, the diagnosis and staging of paediatric HIV

No HIV trained staff HIV infected children cases

are rarely diagnosed

STRENGTH

WEAKNESS

NEONATAL CARE3. CASE MANAGEMENT OF SICK NEWBORN

STANDARD PARAMETER

Summary of assessment

To be strongly

improved(<60%)

Need to be

improved(60-79%)

Good(≥80%)

1.Diagnosis sepsis in neonates 

1. Correct diagnosis of neonatal sepsis 

   

2. Management          

2. Management procedure of neonatal sepsis is in place 

   

2. Specific feeding are give frequently to sick young infants and those with low birth weight.

   

3. Procedures are in place to check the bilirubin level and to manage jaundice    

no SOP/SOP not yet complete administration of 2nd line antibiotics directly no breastfeeding promotion assessment of jaundice based on clinical sign. No SOP to collect blood specimen for infantExchange transfusion not available

no SOP/SOP not yet complete administration of 2nd line antibiotics directly no breastfeeding promotion assessment of jaundice based on clinical sign. No SOP to collect blood specimen for infantExchange transfusion not available

NICU available in 3 class B hospitals and 1 C class hospitals, trained physicians:4 on intensive care (PICU/ NICU), 4 on basic neonatal obstetrical emergency services BEONC, and 15 on CEONCPhototherapy available in most hospitals

WEAKNESS

STRENGTH

Percentage of standard achievement of 10 services in hospitals by provinces

1. Supporting services

2. Emergency services

3. Children’s ward

4. Case management in the pediatrics ward

5. Neonatal care6. Patient

monitoring7. Mother and

child friendly services

8. Hospital support

9. Discharge and follow-up

10. Access to the hospital

Follow up after Assesment

Collaboration MOH,Pediatrician and WHO

Dissemination of pocket book: 2009 25000 copies 2011 25000 copies evaluation of reach, Training CD introducedHospital assessment tool is being revised Improved skills for health personal by routine training Adaptation standard operating procedures Promote quality of health services for community

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THANK YOUFOR YOUR ATTENTION

Thank you

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TERIMA KASIH